Chronic Tension-type Headache Page

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:     Frankp@chiro.org

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Tension type headaches are the most common, affecting upwards of 75% of all headache sufferers. As many as 90% of adults experience tension–type headache. Tension–type headaches usually involve a steady ache, rather than a throbbing one, are described as a feeling of pressure or tightening, may last minutes to days, affect both sides of the head, and and do not worsen with routine physical activity. It may also be accompanied by photophobia or phonophobia (hypersensitivity to light and noise, respectively.). Nausea is usually absent. Some people get tension–type (and migraine) headaches in response to stressful events. Tension–type headaches may also be chronic, occurring frequently or daily. Psychologic factors have been overemphasized as causes of headaches.

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	Long-term Relief from Tension-type Headache and Major Depression Following Chiropractic Treatment J Family Med Prim Care 2018 (May); 7 (3): 629–631~ FULL TEXT We report the case of a 44-year-old school teacher who experienced long-term relief from tension-type headache (TTH) and major depression following chiropractic treatment. It is well recognized that psychiatric comorbidity and suicide risk are commonly found in patients with painful physical symptoms such as chronic headache, backache, or joint pain. Recent studies indicated that autonomic dysfunction plays a role in the pathogenesis of TTHs and depressive disorders. The autonomic nervous system is mainly controlled by reflex centers located in the spinal cord, brain stem, and hypothalamus. This report highlights the rewarding outcomes from spinal adjustment in certain neuropsychiatric disorders. Long-term results of chiropractic adjustment in this particular case were very favorable. Further studies with larger groups are warranted to better clarify the role of chiropractic.
	Do Manual Therapy Techniques Have a Positive Effect on Quality of Life in People with Tension-type Headache? A Randomized Controlled Trial Eur J Phys Rehabil Med. 2016 (Aug); 52 (4): 447–456 ~ FULL TEXT Controversy exists regarding the effectiveness of manual therapy for the relief of tension-type headache (TTH). However most studies have addressed the impact of therapy on the frequency and intensity of pain. No studies have evaluated the potentially significant effect on the patient's quality of life. Post treatment and at the one month follow-up, the combined treatment group (suboccipital inhibitory pressure and suboccipital spinal manipulation) showed improved vitality and the two treatment groups that involved manipulation showed improved mental health.
	Prevalence of Neck Pain in Migraine and Tension-type Headache: A Population Study Cephalalgia 2015 (Mar); 35 (3): 211–219 ~ FULL TEXT In conclusion, we demonstrated that neck pain is highly prevalent in the general population and is more prevalent in individuals with migraine and tension-type headache (TTH). Prevalence of neck pain was highest in coexistent headache and pure TTH followed by migraine. Finally, we showed that myofascial pericranial tenderness is significantly increased in individuals with neck pain compared to individuals without neck pain, indicating a possible shared pathophysiological mechanism with primary headache.
	Effect of Manual Therapy Techniques on Headache Disability in Patients With Tension-type Headache. Randomized Controlled Trial European J Physical and Rehab Med 2014 (Dec); 50 (6): 641–647 Patients were randomly divided into four treatment groups: 1) suboccipital soft tissue inhibition; 2) occiput-atlas-axis manipulation; 3) combined treatment of both techniques; 4) control. Four sessions were applied over 4 weeks and disability was assessed before and after treatment using the Headache Disability Inventory (HDI). Headache frequency was significantly reduced with the manipulative and combined treatment (P<0.05), and the severity and functional subscale of the HDI changed in all three treatment groups (P<0.05). Manipulation treatment also reduced the score on the emotional subscale of the HDI (P<0.05). The combined intervention showed a greater effect at reducing the overall HDI score compared to the group that received suboccipital soft tissue inhibition and to the control group (both P<0.05). In addition, photophobia, phonophobia and pericranial tenderness only improved in the group receiving combined therapy (P<0.05).
	Efficacy of Manual and Manipulative Therapy in the Perception of Pain and Cervical Motion in Patients with Tension-type Headache: A Randomized, Controlled Clinical Trial J Chiropractic Medicine 2014 (Mar); 13 (1): 4–13 ~ FULL TEXT Both treatments (group 1 received manual therapy treatment, group 2 received manipulative treatment, and group 3 received a combination of both treatments), administered both separately and combined together, showed efficacy for patients with tension-type headache with regard to pain perception. As for cervical ranges of motion, treatments produced greater effect when separately administered.
	Referred Pain from Myofascial Trigger Points in Head and Neck-shoulder Muscles Reproduces Head Pain Features in Children With Chronic Tension type Headache J Headache Pain. 2011 (Feb); 12 (1): 35–43 ~ FULL TEXT The current controlled and blinded study showed the existence of multiple active TrPs in head, neck and shoulder musculature in children with chronic tension type headache (CTTH). Both local and referred pain characteristics elicited by palpation of active muscle TrPs reproduced the head pain patterns in children with CTTH. Referred pain areas elicited by active TrPs were larger in children with CTTH as compared to healthy children. The size of referred pain areas of some muscles was positively related to some headache clinical parameters. Our results support a role of active TrP in children with CTTH.
	Effectiveness of Manual Therapy for Chronic Tension-type Headache: A Pragmatic, Randomised, Clinical Trial Cephalalgia. 2011 (Jan); 31 (2): 133–143 ~ FULL TEXT After 8 weeks (n = 80) and 26 weeks (n = 75), a significantly larger reduction of headache frequency was found for the manual therapy (MT) group (mean difference at 8 weeks, -6.4 days; 95% CI -8.3 to -4.5; effect size, 1.6). Disability and cervical function showed significant differences in favour of the MT group at 8 weeks but were not significantly different at 26 weeks. Manual therapy is more effective than usual GP care in the short- and longer term in reducing symptoms of chronic tension-type headache (CTTH).
	Short-Term Effects of Manual Therapy on Heart Rate Variability, Mood State, and Pressure Pain Sensitivity in Patients With Chronic Tension-Type Headache: A Pilot Study J Manipulative Physiol Ther. 2009 (Sep); 32 (7): 527–535 ~ FULL TEXT The application of a single session of manual therapy program produces an immediate increase of index heart rate variability (HRV) and a decrease in tension, anger status, and perceived pain in patients with chronic tension-type headache (CTTH).
	A Randomized, Placebo-Controlled Clinical Trial of Chiropractic and Medical Prophylactic Treatment of Adults With Tension-Type Headache: Results From a Stopped Trial J Manipulative Physiol Ther 2009 (Jun); 32 (5): 344–351 ~ FULL TEXT Although the sample size was smaller than initially required, a statistically significant and clinically important effect was obtained for the combined treatment group. There are considerable difficulties with recruitment of subjects in such a trial. This trial should be replicated with a larger sample.
	Myofascial Trigger Points, Neck Mobility, and Forward Head Posture in Episodic Tension-Type Headache Headache 2007 (May); 47 (5): 662–672 Active TrPs in the upper trapezius, sternocleidomastoid, and temporalis muscles were more common in ETTH (Episodic Tension-Type Headache) subjects than in healthy controls, although TrP activity was not related to any clinical variable concerning the intensity and the temporal profile of headache. ETTH patients showed greater FHP and lesser neck mobility than healthy controls, although both disorders were not correlated with headache parameters.
	Trigger Points in the Suboccipital Muscles and Forward Head Posture in Tension-Type Headache Headache: J Head and Face Pain 2006 (Mar); 46 (3): 454–460 Twenty chronic tension-type headache (CTTH) subjects and 20 matched controls without headache participated. Trigger points (TrPs) were identified by eliciting referred pain with palpation, and increased referred pain with muscle contraction. Side-view pictures of each subject were taken in sitting and standing positions, in order to assess forward head posture (FHP) by measuring the craniovertebral angle. Suboccipital active TrPs and FHP were associated with CTTH. CCTH subjects with active TrPs reported a greater headache intensity and frequency than those with latent TrPs. The degree of FHP correlated positively with headache duration, headache frequency, and the presence of suboccipital active TrPs.
	Non-invasive Physical Treatments for Chronic/Recurrent Headache Cochrane Database Syst Review 2004; (3): CD001878 For the prophylactic treatment of migraine headache, there is evidence that spinal manipulation may be an effective treatment option with a short-term effect similar to that of a commonly used, effective drug (amitriptyline). For the prophylactic treatment of chronic tension-type headache, amitriptyline is more effective than spinal manipulation during treatment. However, spinal manipulation is superior in the short term after cessation of both treatments. For the prophylactic treatment of cervicogenic headache, there is evidence that both neck exercise (low-intensity endurance training) and spinal manipulation are effective in the short and long term when compared to no treatment. There is also evidence that spinal manipulation is effective in the short term when compared to massage or placebo spinal manipulation, and weaker evidence when compared to spinal mobilization.
	Behavioral and Physical Treatments for Tension-type and Cervicogenic Headache Duke University Evidence-based Practice Center (2001) In 1996, the Agency for Health Care Policy and Research (AHCPR) was scheduled to produce a set of clinical practice guidelines on available treatment alternatives for headache. This headache project was based on the systematic evaluation of the literature by a multidisciplinary panel of experts. Due to largely political circumstances, however, their efforts never came to fruition. The work was never released as guidelines, but was instead transformed with modifications and budget cuts into a set of evidence reports on only migraine headache. Thanks to FCER funding, the evidence reports have now been updated on both cervicogenic and tension-type headaches. You might also enjoy Dr. Anthony Rosner's discussion You may download the full 10-page Adobe Acrobat (PDF) version.   You will also enjoy FCER's announcement on the initial publication of the Duke Report.
	Efficacy of Spinal Manipulation for Chronic Headache: A Systematic Review J Manipulative Physiol Ther 2001 (Sep); 24 (7): 457–466 ~ FULL TEXT SMT appears to have a better effect than massage for cervicogenic headache. It also appears that SMT has an effect comparable to commonly used first-line prophylactic prescription medications for tension-type headache and migraine headache.
	Spinal Manipulation in the Treatment of Episodic Tension-Type Headache: A Randomized Controlled Trial ~ FULL TEXT JAMA 1998 (Nov 11); 280 (18): 1576-1579
	Manipulation and Tension Headaches in the AMA Journal Review Bove's 1998 JAMA article (see it, immediately above) on tension headaches and chiropractic, and correspondence with the author. Responses from the academic and research community are also included.
	Spinal Manipulation vs. Amytriptyline for the Treatment of Chronic Tension-type Headaches: A Randomized Clinical Trial J Manipulative Physiol Ther 1995 (Mar); 18 (3): 148–154 The results of this study show that spinal manipulative therapy is an effective treatment for tension headaches. Amitriptyline was slightly more effective in reducing pain by the end of the treatment period, but was associated with more side effects. Four weeks after cessation of treatment however, patients who received spinal manipulation experienced a sustained therapeutic benefit in all major outcomes in contrast to the amitriptyline group, who reverted to baseline values.
	Impact of Migraine and Tension-type Headache on Life-style, Consulting Behaviour, and Medication Use: A Canadian Population Survey Can J Neurol Sci 1993 (May); 20 (2): 131–137 A large sample of Canadian adults was surveyed by telephone to determine the prevalence and characterization of headache, and the effects of headache on life-style, consulting behaviours and medication use. We reported prevalence and characterization in a previous issue; here, we detail the effects of headaches on sufferers. Sixteen and one-half percent of adult Canadians experience migraine and 29% tension-type headaches. In over 70% of headache sufferers interpersonal relationships are impaired. Regular activities are limited in 78% of migraine attacks and 38% of tension-type headaches. Despite this, only 64% of migraine and 43% of tension-type headache sufferers had ever sought medical attention, and of these only 32% returned for ongoing care. Fourteen percent of migraine and 8% of tension-type headache sufferers had used emergency departments. Most headache sufferers take medication, primarily over-the-counter varieties. Measures to reach the headache population are needed, as are safe effective treatment options that will encourage them to participate in their medical care.

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Updated 10-22-2023